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FROM THE FIELD

Providing Care At The End Of Life: Do Medicare Rules Impede Good Care?

Medicare spends more than a quarter of its annual budget on care for those in their last year of life and covers more than 80 percent of decedents.¹ Studies have documented poor quality of care, gaps in care, and patient and family dissatisfaction with care received by dying patients.² Nineteen percent of Medicare decedents, nearly 360,000 beneficiaries, used the Medicare hospice benefit in 1998.³

In recent years we have heard providers report anecdotes about cases in which Medicare coverage and reimbursement rules may have impeded the delivery of high-quality end-of-life care to terminally ill Medicare beneficiaries. Among these anecdotes are . . . [Full Text of this Article]

Overview Of Current Medicare Payment Systems

 

Study Design

 

Hospice

 
Reimbursement rates.Shorter stays and payment system.Rural/urban per diem differential.Hospice "thrivers."Insufficient reimbursement for inpatient respite care.

Home Health

 
Impact of new payment arrangements on quality.Use of infusion therapy to qualify for home health.Uncovered services.

Physicians

 
Billing by nonattending physicians.

Hospitals

 
Early discharge.Unnecessary hospitalization for medication coverage.

Skilled Nursing Facilities

 
RUG-based payment system.Use of infusion therapy to qualify for SNF stay.SNF transfers of dying patients to hospitals.

Medicare Versus Private Coverage

 

Recommendations For Changing Medicare Policy

 
Adopt a patient-level outlier policy for high-cost hospice cases.Explore the need for rebasing hospice rates.Pay a higher per diem for the first and last days of a hospice stay.Explore the level of variation in hospice travel costs.Estimate the net cost of adding some key services.Consider the interaction of hospice per diem rates and Medicare drug benefit.Monitor implementation of the new Medicare home health payment system.Engage in further study of key issues.

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